NWI Alcohol Withdrawal Guidelines - Learning Stream · 2018-06-26 · Adult Alcohol Withdrawal Scale –Stanley et.al. 2003, 2005, 2006 Purpose of the AWGs Simplify Simple straight

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Methodist Hospital

Alcohol Withdrawal

Suggested Guidelines

S. Prizada Sattar, MD Teri L Gabel, Pharm.D.,BCPP

Sidney Kauzlarich, MD Subhash Bhatia, MD Mitzi Bollinger, RN

S. Prizada Sattar, MD 6-20-13

Rationale for the Suggested

Alcohol Withdrawal Scale and

Guidelines CIWA-AR

Developed by tested by experts in the treatment of alcohol withdrawal in detoxification units

Highly subjective scale

Time consuming

Alcohol Withdrawal Scale and Protocol Hybrid of the UNMC and CU Alcohol Withdrawal Scales and

Protocols

Other established and tested Alcohol Withdrawal Scales Australian Department of Veteran Affairs AWS

MINDS (Minnesota Detoxification Scale)

SAWS (Short Alcohol Withdrawal Scale) – Australian

Windsor Clinic Alcohol Withdrawal Scale – UK

Alcohol Withdrawal Scale - Wetterling et. al. 1997 and 2006

Adult Alcohol Withdrawal Scale – Stanley et.al. 2003, 2005, 2006

Purpose of the AWGs

Simplify Simple straight forward approach to treating alcohol

withdrawal

Unify Using the same process, minimizing confusion

Intensify Treat alcohol withdrawal sooner and more assertively

Prevent Prevent the onset of alcohol withdrawal and delirium

Treatment Comprehensive management of the patient in alcohol

withdrawal

Teri L Gabel, PharmD, BCPP 6-07

Time Course of Alcohol Withdrawal

Without Medication


AW Symptom Onset

Symptoms Time to appearance

after last drink

Minor withdrawal symptoms: insomnia,

tremulousness, mild anxiety,

gastrointestinal upset, headache,

diaphoresis, palpitations, anorexia

6 – 12 hours

Alcoholic hallucinosis: visual, auditory, or

tactile hallucinations

12 – 24 hours *

Withdrawal seizures: generalized tonic-clonic

seizures

24 – 48 hours ¤

Alcohol withdrawal delirium (delirium tremens):

hallucinations (predominately visual),

disorientation, tachycardia, hypertension,

low-grade fever, agitation, diaphoresis

48 – 72 hours ¥

* Symptoms generally resolve in 48 hours

¤ Symptoms reported as early as two hours after last drink

¥ Symptoms peak in five days

Lorazepam


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Lorazepam Pharmacology

Acts at the level of the limbic, thalamic, and hypothalamic regions of the CNS, and can produce any level of CNS depression required including sedation, hypnosis, skeletal muscle relaxation, anticonvulsant activity, and coma

Lorazepam potentiates gamma-amino butyric acid (GABA)

Shorter elimination half-life than diazepam BUT it persists longer in the CNS


Lorazepam Pharmacokinetics Absorption

Rapidly absorbed, onset of effect: 20-30 minutes (PO)

Bioavailability 90-93% (PO), 83-100% (IM), 100% (IV)

Distribution Protein Binding

70-90% (can see decreased binding in cirrhosis, chronic alcohol use, and renal insufficiency), Enterohepatic circulation, Brain concentration is approximately equal to the concentration of free drug in the plasma

3 Department Distribution Kinetics 1st distributes rapidly from the central compartment (blood stream) to the shallow peripheral compartment (brain) and then slowly from there to the deeper peripheral compartment (body fat).

Elimination Half-life: 6-12 hours

5 half-lives to steady state Teri L Gabel, PharmD, BCPP 6-07

Lorazepam Metabolism

www.occ-doc.net Teri L Gabel, PharmD, BCPP 6-07

Benzodiazepines

Side Effects

Sedation, dizziness, ataxia, confusion,

amnestic effects

Disinhibition

Delirium

Withdrawal

Activation: anxiety, tremor, agitation

Paresthesias: sensitivity to sound, light, touch

Seizures


Alcohol Withdrawal Scale Scores 0 1 2 3

BP* Systolic < 140

Diastolic < 90

Systolic > 140-175

Diastolic > 90-100

Systolic > 175-200

Diastolic > 100-110

Systolic > 200

Diastolic > 110

Temperature < 99.1 F 99.1-100 F 100-101 F > 101.1 F

Pulse < 90 bpm 90-100 bpm 100-110 bpm >120 bpm

Sweating NONE Mild, Barely visible Moderate Marked, Betting and

Clothes are wet

Tremor NONE Felt/Not visible Mild Moderate/Visible

N/V NONE Upset stomach/nausea Vomiting Severe Vomiting /

Dry heaves

Agitation NONE Increased activity,

above normal

Restless, Fidgety Restless, pacing or

thrashing in bed

Hallucinations NONE Mild – no bother Moderate –

Bothersome

Marked, frightening,

overwhelming**

Sleeplessness NONE Inability to fall asleep

or remain asleep

for 2 hours

Unable to sleep after 4

hours

Not Applicable

* Use higher of the BPs (sBP or dBP) to score this item. ** Use of adjunct Antipsychotic medication recommended

Scoring the AWS Symptoms / Scores 0 1 2 3 Item Score

Patient BP

BP SBP < 140

DBP < 90

SBP > 140-175

DBP > 90-100 SBP > 175-200 DBP > 100-110

SBP > 200

DBP > 110 2

Patient Temp

Temperature < 99.1 F 99.1-100 F 100-101 F > 101.1 F 1

Patient Pulse

Pulse < 90 bpm 90-100 bpm 100-110 bpm >120 bpm 2

Sweating NONE Mild, Barely

visible

Moderate Marked, Betting

and Clothes

are wet

1

Tremor NONE Felt/Not visible Mild Moderate

Visible 1

N/V NONE Upset stomach /

nausea

Vomiting Severe Vomiting /

Dry heaves 1

Agitation NONE Increased activity,

above normal

Restless, Fidgety Restless, pacing or

thrashing in bed 1

Hallucinations NONE Mild – no bother Moderate –

Bothersome

Marked,

frightening

overwhelming*

0

Sleeplessness NONE Inability to fall asleep

or remain asleep for

2 hours

Unable to sleep after 4

hours

Not Applicable 0

Total

Score 9

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In the Urgent Care Area

□ Initial NOW Dose: Lorazepam 2 mg PO/IM

Given IF the patient: Is NOT acutely intoxicated, e.g. no nystagmus or cerebellar ataxia Has elevated vital signs (BP >140/90 AND/OR pulse is >90bpm) BAL does NOT need to be zero to give lorazepam Is demonstrating signs and symptoms of alcohol withdrawal:

tremulousness, diaphoresis, confusion, irritability Has a known history of severe alcohol withdrawal Has a known history of alcohol withdrawal seizures Has a significant drop in Blood Alcohol Level

NOT given IF the patient: Is acutely intoxicated, e.g. presence of somnolence, nystagmus or

cerebellar ataxia


In The ER Area

□ Repeat Dose: Lorazepam 2 mg PO/IM – in two hours If patient is still waiting for transfer

Previous parameters still apply

□ Initiate Alcohol Withdrawal Detoxification Guidelines Consider if patient will be in the ER for a

prolonged period of time

□ Thiamine 100mg PO/IM/IV X 1 PRIOR TO GIVING ANY IV GLUCOSE or Food


On the Unit □ Initiate Alcohol Withdrawal Detoxification

Guidelines

If not already initiated in ER

□ Seizure Precautions

Vital Signs

□ Baseline

□ Q __ hour while awake

□ Other VS order


On The Unit Standing Medications

□ Thiamine 100mg IM/IV X 1 (PRIOR TO GIVING

ANY IV GLUCOSE or Food), then 100mg PO for 1-4

days

□ Folic acid 1mg daily

□ Multivitamin/Minerals one daily

□ Magnesium Oxide 400mg BID or 1gram IM/IV once

(if magnesium levels are <1.5mg/dl)

□ Nicotine patch _____ (7mg, 14mg, or 21mg) – daily

to prevent nicotine withdrawal/craving

□ Any patient specific medications


On the Unit

PRN Medications

□ Phenergan 25mg PO/IM every 4 hours PRN

nausea

□ Antacid 30mg PO every 4 hours PRN GI upset

□ Ibuprofen 600mg PO Q 4 hours PRN headache

□ Clonidine 0.1mg TID PRN for autonomic

hyperactivity

Other PRNS: Ranitidine, omeprazole, …


On the Unit

Antipsychotic Medications – adjunct to lorazepam * For tactile, visual, auditory disturbances /

hallucinations, delusions, combativeness, and/or delirium interfering with medical care and safety and is unrelated to persistent elevation in BP, pulse, or persistent w/d tremors, diaphoresis.

□ Risperidone 1mg PO every 4 hours PRN

□ Haloperidol 2mg IV/IM every 4 hours PRN (when unable to take PO risperidone)

Please monitor for EPSEs.

□ Benztropine mesylate 1mg PO/IM PRN EPSE

No Olanzapine – interaction with lorazepam, and much higher lowering of seizure threshold


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AWS Based Lorazepam Dosing

□ Medication doses are to be HELD if patient is sedated or asleep.

□ Do not awaken a patient to perform the AWS or give them medication.

□ Use oral lorazepam when the patient is able to take oral medications

Lorazepam dose NOT TO EXCEED 24mg in 12 hours without a physician evaluation and order.

Maximum IV push rate: 2mg per minute This is not a dosing interval

□ IF AWS = 0 No medication is given



Mild Alcohol Withdrawal

□ AWS checked every 6 hours for 24 hours

AWS < 5 AND VS <140/90 and pulse <99

□ Lorazepam 1mg PO every 6 hours PRN until patient is asymptomatic

Once consecutive assessments are < 5 over 24hours, discontinue AWS and medications



Moderate Alcohol Withdrawal

□ AWS and VS checked every 2 hours

□ AWS < 5 BUT BP 140/90-175/100 AND/OR pulse is 100-110 bpm

OR

□ AWS 6-10 AND/OR BP 140/90-175/100 AND/OR pulse is 100-110bpm

□ Lorazepam 2mg PO/IM/IV every 2 hours

Once AWS < 6 OR VS have normalized, shift to Mild Alcohol Withdrawal dosing

Taper lorazepam when ready to DC



Severe Alcohol Withdrawal

□ AWS and VS checked every 1 hour

□ AWS >10 AND/OR BP > 200/110 AND/OR Pulse > 120 bpm

□ Lorazepam 2mg PO/IM/IV every 1 hour

AWS < 10 AND/OR VS have normalized, then drop to mild or moderate alcohol dosing guidelines as indicated

AWS < 5 OR VS have normalized, drop to mild alcohol dosing guidelines

Taper lorazepam when ready to DC


Flumazenil *REQUIRED If benzodiazepine is given IM or IV.

In case of over sedation with benzodiazepine:

□ Flumazenil 0.2 mg IV over 15 seconds then 0.2mg IV over 15 seconds if first dose ineffective after 45 seconds. An additional three doses may be given at 60 second intervals to a maximum total of 1mg. After the first 1mg, repeated doses may be given at 20-minute intervals if needed; For repeat treatment, no more than 1 mg (given as 0.5 mg/min) should be given at any one time and no more than 3 mg should be given in any one hour

*Monitor for desired level of consciousness and to prevent triggering alcohol withdrawal seizures


Propylene Glycol Toxicity

Occurs with excessive use of IV

lorazepam

Symptoms of Propylene Glycol Toxicity

Unexplained anion gap, metabolic acidosis,

hyperosmolality, hemolysis, cardiac

arrhythmias, seizure, clinical deterioration,

coma


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AWS Guideline Fine Points Additional lorazepam doses beyond protocol - may

be given as NOW doses on physician electronic, written or verbal order only.

Multiple NOW orders should not be given simultaneously.

Set orders for PRN benzodiazepines are not allowed. Except as indicated in the guidelines.

Pharmacy will no longer honor orders for ranges of benzodiazepine doses.

Cases in which lorazepam doses vary from the established protocol will be evaluated.

Consider the judicious use of other PRN medications for specific symptoms not responding to lorazepam (clonidine, antipsychotics)


Sample AWS Order

□ Seizure precautions

□ AWS and VS to be checked every 1

hour until AWS <10 then every 2 hours

until AWS < 6 then every 6 hours. Once

consecutive assessments are < 5 over

24hours, discontinue AWS and taper

medication.

□ Do not awaken patient for AWS or to

give medication.


Sample AW Order

□ AWS = 0 = NO lorazepam is given

□ Lorazepam 1mg PO every 6 hours PRN AWS < 5 AND VS <140/90 and pulse <99

□ Lorazepam 2mg PO/IM/IV every 2 hours PRN AWS < 5 BUT BP 140/90-175/100 AND/OR pulse is 100-110 bpm OR AWS 6-10 AND/OR BP 140/90-175/100 AND/OR pulse is 100-110bpm

□ Lorazepam 2mg PO/IM/IV every 1 hour PRN NWI AWS >10 AND/OR BP > 200/110 AND/OR Pulse > 120 bpm

□ Flumazenil on unit


Sample Lorazepam Tapers

A. If patient received <24mg/day

• Lorazepam 2mg every 6 hours x 24 hours

Lorazepam 2mg every 8 hours x 24 hours

Lorazepam 1mg every 8 hours x 24 hours,

then DC

B. If patient received >24mg/day

• Lorazepam 2mg every 4 hours x 24 hours



Lorazepam 1mg every 8 hours, then DC


AW Fine Points

It is expected that patients will have some brief

periods of psychomotor agitation while in alcohol

withdrawal. No medication is required for these

brief episodes, instead, reassure the patient

verbally, decrease environmental stimuli, and

use soft restraints when appropriate.

Goal of medication is to PREVENT the onset of

withdrawal and to keep the patient calm or lightly

sedated patient, easily aroused but falls back to

sleep if left alone.


Documents

NWI Alcohol Withdrawal Guidelines - Learning Stream · 2018-06-26 · Adult Alcohol Withdrawal Scale –Stanley et.al. 2003, 2005, 2006 Purpose of the AWGs Simplify Simple straight